Rumination and Rumbling on Vascular Access...

Dr. Hugo Sax (front, right) is the Head of Infection Control, Hospital Epidemiology and a Consultant in Infectious Diseases at the University Hospital of Zurich in Switzerland. A human-factors engineering and implementation scientist, Dr. Sax is perhaps most well known for creating the "Five Moments of Hand Hygiene" which has been adopted by the World Health Organization as the prototypical way of improving hand hygiene.

Dr. Sax recently visited Ann Arbor and our research team (picture). He was kind enough to sit down with me and share his wisdom regarding hand hygiene for the vascular access community. Of note, Dr. Sax completed the ICJME form and disclosed research support from Ecolab for the evaluation of an alcohol-based hand sanitizer product in a previously published study.

VC: Why did you choose hand hygiene as your area of research?HS: I really didn’t' choose it: rather, it chose me. I had the opportunity to organize a nationwide hand hygiene promotion campaign in Switzerland in 2005 and after this I was hooked. Plus, it exemplifies THE challenge in infection prevention, no? Germs are invisible and infection always happen later. This makes hand hygiene operate in a system that basically never gives feedback to your behavior. Such systems are bad teachers: how do we keep doing hand hygiene when nothing perceivable happens when we don’t? So we need to better rely on mental models, as we discuss in this paper.

VC:Why is hand hygiene so important? What data suggests that it helps prevent infection?HS: This is indeed a crucial question! Rather than go into all the data, I wonder if we could do a little survey here? Here is my email: hugo.sax@usz.ch. If you don’t mind, please send me a few words on the exact mechanism by which you think hand hygiene prevents a patient from getting any of the big 4 healthcare-associated infections (primary bloodstream infection, urinary tract infection, pneumonia, or surgical site infection). For example, you may think about how central line infections are thought to come about and in what step exactly hand hygiene would intervene to prevent them. Plus, if you feel comfortable, tell me what went on in your head while you were thinking about this. In return for participating, not only will I answer each email personally, I will also send you the overall result of the survey and a signed reprint of our ‘Five Moments’ paper. We know very little about vascular access providers and hand hygiene so this will be a new and important project I think. Please note: I will treat your answers as absolutely confidential.

VC: Can you tell us a bit about the WHO "My 5 moments of hand hygiene" campaign?HS: When organizing the Swiss Hand Hygiene campaign in 2005, we decided to measure hand hygiene performance before and after the campaign in over 100 hospitals at the same time. That needed a robust concept, one easy to understand, train, and monitor hand hygiene in a broad range of healthcare settings. So we tried a lot of different approaches, did a lot of videotaping and drawing, showed it to various people to tap into what I call their mental models -- that is, how they picture the world around them. Finally, we came up with the idea of five fingers, five moments: thus, making it ‘sticky’ with respect to memory and translation of the concept. But actually, the central piece of the concept is the patient zone, comprising the patient skin and immediate environment, which is colonized with the patient’s microbiome. The goal of this step is simple: no germs in, no germs out.

VC: When inserting vascular catheters, variation in how we perform hand hygiene exists. Some use alcohol-based rubs, other chlorhexidine scrubs or antimicrobial soap with water, etc. Which is best?HS: Alcohol-based handrub is certainly the quickest and most effective way to get rid of the transient hand flora, if the hands are visibly clean. If the hands are soiled, then best to use soap and water.

VC: In your opinion, what are the greatest problems or barriers in performing hand hygiene?HS: I think the biggest problem is cognitive overload - that is, clinicians are often busy doing all sorts of things in the day from thinking about patients to delivering treatments and interventions. Given all of this, its not hard to see how hand hygiene can "slip" out of focus - especially when approaching a patient. The other problem is lack of feedback that occurs if/when you skip hand hygiene. If you don't know you made a mistake, how can you fix it?

One way of solving this problem is to develop what I call "muscle memory" and "cues to action." For example, in Europe, we drive mostly stick shift cars and when we pull up to a red traffic light our hand automatically grabs the stick and shifts it into 1st gear, otherwise we feel uneasy. This happens unconsciously while watching people cross the street or listening to a radio program. Hand hygiene should be the same - an unconscious act that actually puts us at ease.

VC: How has human factors research influenced your approach to studying hand hygiene?HS: I believe that everyone takes genuine pleasure in organized, streamlined work flow. This translates well into my studies of hand hygiene. For instance, it is always a good idea to place dispensers conveniently where they are visible, accessible and can be used. It also makes sense to make sure that people fall in love with the experience of using them – a bit like car makers purposefully design the sound and feel of a shutting door of an expansive sports vehicle to be an addictive experience. I view hand hygiene much the same way - a safety component that can be designed such that it is easy, accessible and enjoyable for all those that useit.

VC: If there was one thing you hoped people would know about hand hygiene, what would that be?HS: That our hands are meant to heal!

​Please do take the time to email Dr. Sax regarding his hand hygiene survey by emailing him here. Dr. Sax will keep all replies confidential and will reply to your emails individually.

Sheila Inwood is a vascular access specialist who was among one of the first nurses to place central catheters in the UK and the first to surgically place an implantable port. She has worked with industry, academia and clinicians to improve the care of patients that need vascular access in her NHS hospital. Ms. Inwood has served as Keynote Speaker at a number of international meetings including WoCoVa and the Association of Vascular Access.

Ms. Inwood has completed the ICMJE disclosure form and has indicated no current conflicts of interest. She has served as the Director of International Medical Affairs and Clinical Affairs for CareFusion and has been a CVC faculty member for Teleflex Inc. in the past.

VC: Tell us a bit about yourself, where you work, what you do and how you came to be where you are?SI: I work in an 800-bed general hospital. My background in nursing is in the critical care, cardiothoracic area. I established the first IV nutrition nurse post at the hospital in 1987. The primary objective of the position was to enable IV nutrition to be administered around the general hospital, not just in ICU. A huge amount of my time was spent finding someone / anyone to insert a cuffed tunnelled central catheter. This was the only way intravenous nutrition was given (such a long time ago!)

Needless to say the variety of expertise, and knowledge that I encountered during those years as a nutrition nurse was extremely broad. There was no standardised method, level of expertise or equipment for inserting catheters. The supposed level of expertise was firmly in the hands of the anaesthesia department. Failing their support, it was very common to have patients waiting for a catheter to be surgically inserted by a surgeon.

Hand in hand with a visionary anaesthetist, we established a comprehensive vascular access service (VAS) in 1993 providing this to all areas of the hospital. I should clarify when I say that ours was a service that could insert all types of vascular catheters: Traditional, cuffed tunnelled, acute CVC, PICC, dialysis. It truly brought vascular access to the patient in a way that didn't happen before.

VC: I sense the passion in your response, but tell me why you chose the field of vascular access nursing as a career choice? What is it that excites you the most about this work?SI: I found I could really make a difference. Part of the service delivery was that catheters were placed at the bedside -- when the patient required it. Rather than the patient being moved around the hospital to suit the location of the inserter, the service was delivered to the patient wherever they might be which I found very powerful

I also think vascular access may seem quite simple and straightforward to some, but it has a breadth and depth that never seems to end. It may appear at first glance to be a repetitive process but the one variable that constantly changes are the patients that require your service and expertise. Add to this changes in the accompanying technology (the female version of boys with their toys) and expertise that only grows with time.

VC: What are some of the biggest problems you face on a daily basis as a vascular access specialist?SI: One problem is that everything thinks they are an “expert” when it comes to vascular access, from peripheral to central lines. I believe this is because in many settings no one particular group “owns” this field. Subsequently, I often get referrals for a PICC, not a vascular access assessment or evaluation to determine what a patient may need. My way of dealing with this problem is to always accept the referral, but explain that I will review the patient and make a decision as to what would be the most appropriate access for their needs. This is a long-term education / culture change process that never ends. I would add that this philosophy only functions if a vascular access specialist such as myself can offer all the choices of vascular access. Meaning if I assess a patient and determine they require a CVC and not a PICC, I need to be able to place it for the patient and the referring provider. If you hold the title of vascular access specialist, you need to have the experience and skill set that justify the title across all devices.

VC: So given this issue, what do you think are the biggest challenges facing the field of vascular access access today and how do we move the field forward?SI: I think one of the biggest challenges is on our end. For instance, I am not 100% certain that PICC teams are vascular access specialists. Rather, they need to understand their limitations and push to be able to place all types of devices - so that the patient gets what is best for them, not what is available.

Another challenge and area for innovation is a manufacturer’s / industry’s ability to keep up with the appropriate / safest products, technology. There is a real illusion that industry works hand in hand with practitioners; in my opinion, this is not always true. Rather, practice, technology is driven (sadly) by marketing. There needs to be a lot more collaborative cooperation particularly at the R&D stage. Industry needs to work in sync with clinicians so that the needs identified by us can be met by emerging technology.

VC: If there were one vascular access policy change you could make, what may it be and why?SI: That's easy. All patients should be referred to a vascular access specialist, who is an expert and competent in all areas of vascular access. Just as a patient that may need surgery is referred for a surgical consult, vascular access should be a speciality in its own right. Last I checked we didn’t ask the surgeon to come down to the ER and do an appendectomy now, did we?

Context is everything when it comes to scientific enquiry. The right questions, the right approach and an answer that appears balanced, logical and reasonable are keys to credibility.

Despite this truism,we know well that context is a moving target. And in order to be right on topic - we believe it's important to listen to the voices of many in the Vascular Access Community.

So, new to the website this year - we are adding "Guest Blogs" from invited hosts. These blogs will be authored by pioneers whose voices, work, achievements and opinions matter to all of us in the field. But no free passes here - we will ask them tough questions about context, relevance and the challenges ahead for the field, perhaps some that are uncomfortable or controversial as well.

We've got a star studded cast lined up for the first few posts and plan to bring you these refreshing perspectives every so often in 2016. In keeping with ImprovePICCs goal to remain bias-free, please note that this isn't a megaphone for industry or those with substantial conflicts of interest. All bloggers are required to submit the ICMJE conflict of interest form and these will be reported with their post. The decision to post something is reserved by us and will be based on myriad factors, including suitability and perceived conflict of interest.

This isn't just a club for the elite, though. We do want to hear from those of you in the front lines who have something important and relevant to tell the vascular access community. If you're up to it - draft us a brief outline of a blog you want to write and send us a note using the Contact Us page. We would love to hear from you! Remember the rules regarding Conflicts of Interest and the fact that the decision to post is reserved by us based on content, scope, interest, etc.

And even if you're not interested in writing a blog, tell us what you think by commenting on this or the other guest blog posts. We will be watching these with interest!